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a FOR OFFICE USE., y `- APPLICATION FOR SANITATION PERMIT Permit No. ... ,7_ S ---------------------- -- ------------------------------- (Complete in Duplicate) Date Issued ---- ------- --- __.---_._.-.----___-.___.-__ This Permit Expires 1 Year From Date Issued Application is hereby made to the Sang Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. -------------------------- ------------------------------------------------ JOB ADDRESS AND-LOCATION Owner's Name I ------- Phone----------------------------------- - ------- - - Address- ��,,� -----------------•--- Contractor's Name--------• - l� -- --------------- Phone Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __G--_ Number of bedrooms _ -_ Number of baths __1--- Lot size �.Q- / __, ----------------------------- Water Supply: Public system PKIc8mmunify system ❑ Private ❑ Depth to Water Table Character of soil to a depth of 3 feet Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 9?"'Hardpan ❑ Previous Application Made: {1f yes,date--------------------) No New Construction: Yes ❑ No Z?1*'_FHA/VA: Yes ❑ No l TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Se tic Tank:., Distance from nearest well--_-------------Distance from foundation--------------------Material _-.------------.-------------__----____------ CS�Off No. of compartments------------- - ----------Size_--------------•--------- -- ---Liquid depth---------------- --------Capacity.-.-------------------- Disposa,Fiel�: Distance from nearest well.... ............Distance from foundation--------------------Distance to nearest lot line----------------- 0 v i Number of lines-- --------Length of each line---------------------------_Width of trench ---------------------------------- Type of filter material-------------------------Depth of filter material-----------------------Total length------------------------------------------ i r Seepage Pit: Distance to nearest well---�r-.---_--Distancefr m fo ndation--_l'�...._._.Distance to nearest lot Number of pits---- --------------Lining material---fsP __.Size: Diameter. o K_----- --- ---Dept h o /-------------------- Cesspool: Distance from nearest well-----------------Distance from foundation------------------- Lining material--._----_-_------------_-_--------_-. ❑ Size: Diameter--------=-------- -------------------Depth------------------------------------- --------------Liquid Capacity------------------ ---------gals. d f .--Distance from nearest buildin Privy: Distance from nearest well------ ----- ----------------- -------- --g------------------- - ----------------- V� Distance to nearest lot line------. 2 Remodeling and/or repairing (describe): " -----•- •----- -- r -- ---------------•--------------------------------------------------- , -------------------------------- ------------- ------------ --- --------------------------------- --------------------- --------------------------------------------------.------------------------------------------------------------------------------------------------ - ------------------- 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County? ordinances, State laws, and rules and regulat'ons of the San Joaquin Local Health District. (Signed]------------------ -- -{�or Contractoo: -- -- -------- BY� 1 -------------- ' ---------(Ti+le] � - -- -. .--------------------- ------ -- By: plan, showing size of lot, location of system in rel n to wells, buildings, etc., can be placed an reverse side). i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY__ ----- ------------------------- DATE �7 - = G�� -------- REVIEWEDBY------ ------------------------------� - - ----- --------- DATE-------- --- ----- - BUILDING PERMIT ISSUED_----------- ±� ,, ` .D TE------------------------------------------------------------- �' -- - ----•-•---------------------------------•--------------------------- Alterations and/or recommendations:_____ �__... - ==------ -------------- -------------•------------------ --------------------------------------------------------------- --------------------------------------- --- - -------------------------------------------------------------------------------------------------- I ----------------------------- ------------ � `-_.�— - - l FINAL INSPECTION BY:.-- p - - --------- ---------- ----_-------- Date--...� �.r `_ - -`�'_-` -- ---------------------------- ----- -------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haselton Ave. t; 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California F.F.Cfl. -J